The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Increase intake of proteins, take vitamin C and zinc

Use care when walking to avoid bumping your limb

Cleanse the ulcer with soap and water

Apply cortisone cream to decrease itching

Put on compression stockings before getting out of bed

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale

Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.

Choice B rationale

Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.

Choice C rationale

Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.

Choice D rationale

Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.

Choice E rationale

Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.

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Correct Answer is A

Explanation

Choice A rationale

Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, usually in the leg. One of the most common symptoms of DVT is swelling of the affected extremity. This occurs because the blood clot obstructs the flow of blood, causing fluid to build up in the tissues.

Choice B rationale

While redness can be a symptom of DVT, it is not typically confined to a small area. Instead, redness associated with DVT is usually more widespread and is often accompanied by other symptoms such as swelling and pain.

Choice C rationale

A cool, mottled extremity is not a typical symptom of DVT34. DVT usually causes the affected area to feel warmer than the surrounding areas due to inflammation caused by the blood clot.

Choice D rationale

The presence of bilateral peripheral pulses is not a specific finding for DVT34. In fact, the presence of strong peripheral pulses may suggest that blood flow is not significantly obstructed.

A. Fourth intercostal space, right sternal border B. Second intercostal space, right sternal border C. Fifth intercostal space, left midclavicular line D. Third intercostal space, left midclavicular line .

Correct Answer is C

Explanation

A heart murmur due to mitral valve disease is typically heard loudest over the mitral area, which is located at the fifth intercostal space in the left midclavicular line.

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The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client with a heart murmur due to mitral valve disease. Where would the nurse hear the murmur the loudest?

Correct Answer is C

Explanation

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